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10080168CITY OF CUPERTINO BL ILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 297 OWNER'S NAME: KORET FOUNDATION ER'S PHONE: 4082530200 LICENSED CONTRACTOR'S DECLARATION License Class Lie. # Contractor I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. ISignatyre Date I V OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three r Vv" declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked-�. A APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save mify and keep harmless the City of Cupertino against liabilities, judgments, , and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. _ /1 1, r 1 CONTRACTOR: KORET FOUNDATION PERMIT NO: 10080168 20875 V 4LLEY GREEN DR DATE ISSUED: 08/24/2010 CUPER I'INO, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r— MECH r— RESIDENTIAL r— COMMERCIAL JOB D ESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMM'L APT BLDGS Sq. Ft Floor Area: Valuation: $500 APN Nr mber: 32609041.297 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 18) DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: All roof; shall be inspected prior to any roofing material being installed. If a roof is installec without first obtaining an inspection, I agree to remove all new materials for inspection. Signatui a of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have r ead the hazardous materials requirements under Chapter 6.95 of the Califor ria Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain complis nce with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety t'ode, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health 3: Safety Code, Sections 25505, 25533, and 25534. wner oDr thoriz Z� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for whir h this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I under: tand my plans shall be used as public records. 2,51 / CI/ D I Licensc d Professional CITY OF CUPE RTINO PERMIT RECEIPT OPERATOR: patg 8 ITEMS OF 8 COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lct: APN 32609091.297 DATE ISSUED ....... : 080000:_1263 RECEIPT # • • • • " . . 100801f�8 REFERENCE ID # •• SITE ADDRESS .....: 20975 'IALLEY GREEN DR APT 297 SUBDIVISION ....... CUPERTINO CITY ............ IMPACT AREA ...... OWNER KORET FOUNDATION ADDRESS ..........: 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPER'IINO, CA 95014 RECEIVED FROM ....: VILLAC,ES KORET CONTRACTOR ........ LIC' # *OWNER* COMPANY ..........: KORET FOUNDATION ADDRESS ..........: 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPER-INO, CA 95014 TELEPHONE ......... AMOUNT -- REFERENCE NUMBER METHOD OF PAYMENT ------- ------ CHECK 253.50 $19895 TOTAL RECEIPT 253.50 QUANTITY AMO 7NT PD -TO -DT THIS REC NEW BAL FEE ID UNIT ---------- 100 0.00 ---------- 1BCBSC ------------ VALUATION 500.00 1.00 42.00 0.00 0.00 . 42.00 0.00 1BREMRECEP NO. OUTLETS 1.00 500.00 0. 50 0.00 0.50 0.00 0.00 1BSEISMICR VALUATION 1. 00 42.00 0.00 42.00 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1MPERMITFE FLAT RATE 1.0 42. 00 0.000 42.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PRREPIPE NO OF FIXTURE 1.00 42.00 0.00 42.00 1TRAVDOC FLAT RATE _ ---------- ---------- --------- 0.00 253.50 0.00 253.50 TOTAL PERMIT AMOUNT -- REFERENCE NUMBER METHOD OF PAYMENT ------- ------ CHECK 253.50 $19895 TOTAL RECEIPT 253.50 i CITY Of CUPEI�TINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # Date: Building Address: -D-Oq 7�6 VA -t ,6. &-Crt r,) 2 x Mailing Address (if different from building address): Owner's Name: �� T�,9N,0i 1 Phone #: 4610 ' .2-.5 3 --0-2-00 HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Contractor: TBD Phone: Fax: Contractor License #: -T 13D Cupertino Business License #: Contact: M IC1ki4�L T2l��72 Phone: L106 _ 2-52 _?6, q.3 -- Fax: 1406- -173 -/02-5 Residential Commercial Job Description: xA)�� Li PS14L�)ok�� OA)lr � `7141 GO vn m l W— .%} p n} iZ mEI�T " s t 1. I L D t At s" Building Permit Info: Bldg LJ Elect Nf Plumb Mech Type of Construction (Usage Class): Occupancy Type: L /4--2- ( 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B EV _ - Valuation:/04:� Square Footage: Project Size: Express ❑ Standard LId' Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: Fc r help, contact Build it Green at www.builditgreen.c r Revised 02/05/09 CUPERTINO OWNER -BUILDER DISCL0:3URE FORM COMMUNITY DEVELOPMENT DEPARTME14T • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 •bund no(dcuoeriino.oro Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS �e -11 APII_ _ BP# OWNER NAME OWNER ADDRESS In -< Z0%,P)7 5 v �Arire ,� G ✓� e .� DESCRIPTION OF WORK: r►3s wC2 We are providing you with an Owner -Builder Acknowledgmeni and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by havinc this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initiafed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below `o signify you understand or verify this information.) understand a frequent practice of unlicensed per.3ons is to have the property owner obtain an "Owner - building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable anc subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my i72. ce coverage for injuries to workers on my property. I understand building permits are not required to t;e signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 'NAI understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 1 understand Contractors are required by law to bo licensed and bonded in California and to list their license number on permits and contracts. . I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I maybe considered an "employer" under state and federal law. V� _1Ui6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workors' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject ,meto serious financial risk. Wh:n7. 1 understand under California Contractors' State license Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the it tent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures do,:s not exceed four within any calendar year, or all of the work is pert rmed under contract with a licensed general build ng Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 0;4',nerBui1derFo777: 2010.doc revised 04/14/10 )mAj lunderstand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also u iderstand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contrac ors. 'WAJ 10. I am aware of and consent to an Owner -Builder t uilding permit applied for in my name, and understand that I am the party legally and financially responsible for propos :d construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. �(1�V1-.t 12. I agree to notify the issuer of this form immediate y of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated 'by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a res ult of a complaint.iYour only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. ' Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city mvy be required to be presented when the permit is issued to verify the property owner's si nature. Property Owner's Signature: ' Date: - ---- - ---- - ---------------------------------------------------•-------------------- ------ -- -- ---- ---- --- ----- --- ------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit f )r the Owner -Builder). AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of whicf, I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): W }p Project Location or Address: `� O E b 4 U CSA �e vee ," b V- �} l Name of Authorized Agent: y ,� Q„ r�C �� ,,, Q�� Tel No '{ 05-77 7 — G 7 3 d Address of Authorized Agent: 2 y % 7 I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presen ed when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: �5 GivnerBuilderForns 1010.doc revised 04/14/10